Download Multiple Activity

Notice of UMPhysicians Clinician Volunteer Activity
[Multiple Activity Form]
Please report all volunteer activities for which you provide clinical services and are looking to UMPhysicians malpractice insurance policy to provide coverage. The activity
may occur once per year or more frequently. This information is needed by UMPhysicians to ensure insurance coverage.
Physician name:
CSU
Telephone number:
Name, address, telephone # of
organization
Dates & description of services you
provide (or attach)
Separate
malpractice
coverage?
If yes, name of carrier, scope of coverage
& policy limits (or attach)
Physician Signature
Date
Division Director Approval
Date
Department Head
 Activity furthers the mission, vision and value of UMP and should be support by the CSU
 Activity does not further the mission, vision and value of UMP and will not be supported by the CSU
 Letter sent to physician notifying that activity has been denied
Department Head Approval
___________________________________
Written contract?
(If yes, please attach copy)